In this article, we’re diving deep into Thoracic Outlet Syndrome, what causes it, and what you can do to fix it.

What Is Thoracic Outlet Syndrome?

The “thoracic outlet” is like a tunnel or a channel for nerves and blood vessels to get from your neck and upper back/chest to the arm and the shoulder. It’s created by muscles in your neck and shoulder, the clavicle (collar bone), the upper ribs, and some other ligaments and tendons. When the muscles, bones, or other tissues in this region aren’t moving right, they can squish the contents of this thoracic outlet, creating Thoracic Outlet Syndrome (TOS).

There are two major types of Thoracic Outlet Syndrome:

1. Neurogenic TOS - Neurogenic TOS is caused by compression of the nerves of your brachial plexus, the nerves that go to your arms and hands. This condition makes up 90% of TOS cases and creates nerve symptoms like numbness, tingling, or weakness in the hands, arms, and shoulders.

2. Vascular TOS - Vascular TOS is much rarer and often more concerning, caused by compression or obstruction of the veins or arteries in the thoracic outlet. The symptoms of Vascular TOS can include redness, swelling, or color changes in the hands and arms, as well as cold hands or arms that are cold to the touch.

For this article, we’ll be focusing on neurogenic TOS, since that’s the most common. Just know that if you’re having any numbness or tingling in the arms and hands accompanied by redness, swelling, color/temperature changes, or aching pain, you may have vascular TOS, which can be a significant issue that you shouldn’t try to manage on your own. If you’re experiencing the symptoms listed, please make an appointment with a healthcare professional sooner rather than later.

We can also break down TOS by the cause of the issue. There are three major causes of TOS:

1. Scalenes - Your scalenes are muscles on the sides of your neck that work to bend your neck from side to side. There are three of them on each side - the anterior, middle, and posterior scalenes. In between the anterior and middle scalene muscles, nerves exit your spinal cord, going towards the arm. When the scalenes get tight, they can squish these nerves and cause neurogenic TOS.

2. Clavicle/Ribs - Once the nerves pass through the scalenes, they travel underneath your clavicle (collar bone). If your clavicle isn’t moving correctly or the subclavius muscle is too tight, the nerves and blood vessels can get squished between the clavicle and your first rib (which sits just underneath the collarbone).

3. Pectoralis Minor - The final problem point for TOS is the Pectoralis Minor, a small muscle underneath your larger pectoralis major (your pec muscle) that runs from your ribs up to your shoulder blade. When this muscle gets too tight, it can squish the nerves and blood vessels between itself and the ribs, creating the symptoms of TOS.

Most commonly, TOS will arise from a postural issue, like slouching over a computer or phone all day long. Movement deficiencies and muscle weaknesses or imbalances can also cause TOS, as muscles will often get tight if they’re being used too much or trying to work too hard. Athletes can develop TOS as well, depending on their sport, musculature, and past history of injury.

There are other issues that can cause TOS as well, though these are less common. Pregnancy can cause you to retain extra water and swell up, putting pressure on these nerves. Congenital issues, like cervical ribs (ribs coming off the lower vertebrae of your neck) can cause squish those nerves as well. Trauma, like a car accident or head/neck injury, can also cause TOS. Rarely, a tumor can grow and press on the nerve and blood vessels in the thoracic outlet, creating symptoms as well. For this reason, it’s important to have your symptoms evaluated by a healthcare professional, primarily to rule out these causes that aren’t really treatable at home.

Now that we’ve covered the causes of TOS, how do you know if you have TOS?

How To Tell If You Have Thoracic Outlet Syndrome?

The best way to figure out if your problems are being caused by TOS or some other issue is to schedule an appointment with a healthcare professional, like Dr. Carlson at Northbound Chiropractic. That said, reading through the symptoms of TOS and doing some movements/tests yourself might indicate if TOS is an issue for you or not.

The symptoms of neurogenic TOS include:

• Numbness or tingling in your arm or fingers

• Pain or aches in your neck, shoulder, arm, or hand

• Pain or numbness that get worse when moving your arms overhead or behind you

• Weakening grip

• Arms that get tired quickly

• Atrophy or shrinking of muscles in your arms and hands

There are also three maneuvers you can try at home to see if symptoms show up. These tests stretch certain tissues to see if anything is causing problems.

• Test 1: The Elevated Arm Stress Test - To do this test, bring your arms up to shoulder height with your hands above your head, then clench and unclench your fists. Do this for 60 seconds (or up to 3 minutes if you're committed) or until your start experiencing symptoms (numbness and tingling are the most common). If you do get numbness and tingling, this indicates that you may have a thoracic outlet-related issue. If you don’t get symptoms, this doesn’t mean that you don’t have an issue, just that the test couldn’t replicate it. Wait until symptoms subside and move on to the next test.

• Test 2: The Doorframe Stretch Test - For this test, find a doorframe, and hold onto it with your hands/arms on each side, with your hands/arms at shoulder height. Lean through the doorframe like you’re stretching your chest. Go as far as you can without causing pain or putting yourself at risk of falling. Hold here for 15-30 seconds or until symptoms arise. Repeat this test with your arms/hands above your shoulders and with your arms/hands below your shoulders, holding each again for 15-30 seconds or until symptoms arise. (The 3 angles stretch different tissues to check for issues with any of them.)

• Test 3: The Hyperabduction Test - With this test, you’ll bring your arm as far as you can behind you, then slowly bring it above your head as far as you can while keeping your arm behind you. Hold at the end of your range of motion for 10 seconds, or stop whenever you start feeling symptoms. This test stretches your pectoralis minor to see if it’s tight enough to create problems.

If you’ve done all three of these tests and any or all of them created symptoms, you may have TOS. If you’ve done all three of these tests and none of them caused symptoms, you may not have TOS, but there’s no guarantee; you just may not have been able to stretch the tissues enough to create the symptoms yourself. Regardless, at this point, if you’re still suspicious of TOS, it’s likely time to see a healthcare professional.

How Is Thoracic Outlet Syndrome Treated?

Treatment for Thoracic Outlet Syndrome depends on your specific cause, but the approach is almost always multifaceted to address both the physical cause and any movement or lifestyle factors that may be contributing to your symptoms.

A treatment plan for Thoracic Outlet Syndrome could include:

• Chiropractic Adjusting - Chiropractic adjusting of the neck and upper back helps to restore proper motion and may reduce tension on the nerves causing TOS. Additionally, adjustments in these areas can relax tight muscles (like the scalenes) and improve motor control. Clavicle, shoulder, and wrist adjustments can also help to manage causes of TOS.

• Soft Tissue Manipulation - Soft tissue manipulation (like assisted stretching and manual therapy) can relax tight muscles, like the scalenes, subclavius, and pectoralis minor, that may be compressing nerves and causing TOS symptoms.

• Corrective Exercises - Once we’ve relaxed the soft tissues and ensured that everything is moving well, we need to keep it that way. Stretching and strengthening exercises will help to address whatever biomechanical- and movement-related factors are causing your TOS. These exercises will be targeted for your specific situation, addressing both muscle imbalances and the actual tightness causing TOS.

• Lifestyle Changes - Certain lifestyle factors need to be modified to help manage your TOS. Most commonly, these factors include posture and overuse. Poor posture will tighten up muscles related to TOS, particularly the scalenes and the pectoralis minor; ensuring you sit with good posture and that you're changing positions frequently can help with TOS. Additionally, avoiding repetitive or frequent overhead activities when possible can help manage your TOS, particularly while you’re still being treated. These overhead movements are not bad in and of themselves, but if you have TOS or have had it in the past, you need to address certain deficiencies that might be causing TOS-related muscles to tighten up.

How Can I Manage Thoracic Outlet Syndrome At Home?

If you have TOS or think you do, it can be challenging to manage your condition on your own, particularly because you may not be able to figure out what exactly is tight. That said, there are some things you can try to see if they’ll help improve your symptoms.

• Focus On Posture - Ensure that you’re sitting with good posture. If you work at a desk or on a computer, make sure you have a good set-up, with a monitor at eye level and a keyboard that allows your arms and wrists to be relatively relaxed. If you spend a lot of time reading or using a tablet or phone, try to hold them closer to eye level rather than in your lap. And for anyone, the biggest posture tip is this - your most important posture is your next posture - meaning that you should change positions frequently, at least every 5-10 minutes. Whether this is going from sitting up straight to slouching, turning your body slightly, or standing up and going for a walk, any change in position is the best thing you can do for your posture.

• Bruegger’s Relief Position - Sit up straight and tuck your chin/head back (imagine lining your ears up with the middle of your shoulders). Bring your arms up overhead and slowly draw them down and back, opening up your chest and bringing your shoulder blades together. Feeling a good stretch through your chest and shoulders, hold this position while breathing deeply into your abdomen for 15-30 seconds (or longer). Repeat this at least every hour while you’re sitting/sedentary, and at least 5 times throughout the day if you’re dealing with TOS.

• Neck Stretches - Start by bringing your left ear to your left shoulder, then putting your left hand on the right side of your head. Push gently into your hand and hold for 10-15 seconds, moving deeper into the stretch when/if you can. Turn your head/nose to the ceiling slightly then push again into your hand and hold for another 10-15 seconds.

• Median Nerve Flossing - Tilt your head away from your affected arm/hand, and bring that affected side hand to your chest. Then, tilt your head toward the affected side while you bring your arm down and across your body, gradually extending your wrist back as you go. Repeat this motion 10 times. Do 3-4 sets of this per day, or as needed to relieve symptoms. This is only for numbness and tingling in your thumb, index, middle, and sometimes ring fingers - if you have numbness and tingling elsewhere, you may not get relief from this movement, but you might from a different nerve flossing exercise.

These are all options for you to try at home to see if you get any relief. As with anything, TOS might take some time to improve after starting a new routine, so give it a few days. If you don’t see any improvement, then it’s time to consider scheduling an appointment with us!

Parting Thoughts

Thoracic Outlet Syndrome is a somewhat complex condition that has many different causes and contributing factors. While it’s possible to manage it on your own, it may be worthwhile to see a healthcare professional to get an accurate diagnosis, rule out anything concerning, and point you in the right direction.

At Northbound Chiropractic, we are here to help you get on the right path, whatever that is for you. Click the button below or call or text us at (763) 373-9710 to learn more about scheduling an appointment with us.

Giving you my best,
Dr. Nicholas Carlson
Northbound Chiropractic
Serving Delano, MN, Maple Plain, and the rest of Wright and West Hennepin Counties